1 KEY REFERENCES Laying the foundation for D. of ABCDEF Bundle Ely E. JAMA. 2001;286:2703-2710 (CAM-ICU). Bergeron N. Intensive Care Med. 2001;27:859-864 (ICDSC). Dubois M. Intensive Care Med. 2001;27:1297-1304 (Risk Factors). Ely E. Intensive Care Med. 2001;27:1892-1900 (LOS and Risk Factors). Ely E. JAMA. 2004;291:1753-1762 (Delirium Mortality). Pisani M. Am J Respir Crit Care Med. 2009;180:1092-1097 (Delirium Mortality). Shehabi Y. Crit Care Med. 2010; 38:2311 2318 (Delirium Mortality). Schweickert W. Lancet. 2009;373:1874-1882 (Delirium Reduction). Needham D. Arch Phys Med Rehabil. 2010;91:536-542 (Delirium Reduction). Colombo R. Minerva Anestesiol. 2012;78:1026-1033 (Delirium Reduction). Gusmao-Flores D. Crit Care. 2012;16:R115 (Meta-Analysis of Tools). Balas M. Crit Care Med.
2 2013;42:1024-1036 (Delirium Reduction). Kamdar B. Crit Care Med. 2013;41:800-809 (Delirium Reduction). Course Objectives Define delirium and manifestations Discuss the impact of delirium on patient outcomes Review tools to measure delirium Confusion Assessment Method for the Intensive Care Unit (CAM-ICU), Intensive Care Delirium Screening Checklist (ICDSC). Identify strategies to build an ICU attentive to delirium Examine general principles, non-pharmacologic and pharmacologic interventions for the management of delirium Creating a Standard Language Barr J Crit Care Med. 2013;41:263 306. Articles Published on Delirium Slide: E Wes Ely, MD Vanderbilt University Delirium: Key Features (DSM-V). A. Disturbance in attention and awareness B. Disturbance in cognition: , memory, disorientation, language, perception C.
3 Develops over a short period of time and tends to fluctuate during the course of the day D. Disturbances are NOT better explained by a preexisting, established or evolving neurocognitive disorder and do NOT occur in the context of a severely reduced level of arousal such as coma E. There is evidence from the history and physical exam and/or labs that the disturbance is caused by a medical condition, substance intoxication or withdrawal, or medication/toxin side effect American Psychiatric Association. DSM-V. Washington DC; 2013. Associated but Nondiagnostic Symptoms of ICU Delirium Hallucinations, delusions Abnormal psychometric activity ( , agitation, lethargy). Emotional disturbances ( , fear, anger, depression, apathy). Sleep disturbances Delirium: Motoric Subtypes Combative Hyperactive Delirium (~1%).
4 Agitated Restless Alert and Calm Mixed Delirium (64%). Lethargic Sedated Stupor Hypoactive Delirium (35%). Peterson JF J Am Geriat Soc. 2006;54(3):479-484. ICU Delirium: Pathophysiology Cholinergic activity Genetic Dopaminergic predisposition activity Primed / Serotonergic microglial cells activity GABA/NMDA. receptor imbalance Cavallazzi R Ann Intensive Care. 2012;2(1):49. Delirium: Epidemiology and Short-Term Outcomes Prevalence 50% to 80% of mechanically ventilated patients 20% to 50% of lower severity patients Associated outcomes Prolonged hospitalization Increased mortality Increased cost Ely E JAMA. 2001;286:2703-2710. Dubois M. Intensive Care Med. 2001;27:1297-1304. Ely E JAMA. 2003;289:2983-2991. Ely E JAMA. 2004;291:1753-1762. Thomason JW. Crit Care. 2005;9:R375-81.
5 Milbrandt EB Crit Care Med. 2004; 32:955-962. Delirium: Long-Term Outcomes Mortality Each day of delirium in the ICU increases the hazard of 1-year mortality by 10% 1. Cognitive Impairment ICU delirium is an independent risk factor for long-term cognitive impairment 2,3. 34% with scores similar to moderate TBI. 24% with scores similar to mild Alzheimer disease 1 Pisani MA Am J Respir Crit Care Med. 2009;180:1092-1097. 2 Girard T Crit Care Med .2010;38:1513-1520. 3 Pandharipande PP N Engl J Med. 2013;369(14):1306-1316. PAD Delirium Assessment Recommendations Routinely monitor for delirium in all adult ICU. patients (+1B). Use either: Confusion Assessment Method for ICU (CAM-ICU). Intensive Care Delirium Screening Checklist (ICDSC). Barr J Crit Care Med. 2013;41:263-306. Assessment: Coma vs.
6 Delirium Coma: defined by level of arousal SAS 1 or 2, RASS = -4 or -5. Only responsive to physical or noxious stimulus, if at all Unable to communicate Comatose patients should be reassessed over time to permit delirium scoring Scoring is optimal during a patient's maximal level of wakefulness Eligible for delirium when they arouse to verbal stimulus RASS -3: brief eye opening to voice, no contact SAS 3: awakens to verbal stimulus, but drifts off Confusion Assessment Method (CAM, CAM-ICU). Feature 1: Acute change or fluctuating course of mental status And Feature 2: Inattention And Feature 3: Altered level of Or Feature 4: Disorganized consciousness thinking Inouye SK Ann Intern Med. 1990;113:941-948. Ely E JAMA. 2001;286:2703-2710. CAM-ICU Flowsheet Pooled Test Characteristics: Sensitivity 80%.
7 Specificity 96%. > Figure: Gusmao-Flores D. Crit Care. 2012;16:R115-R125. Intensive Care Delirium Screening Checklist (ICDSC). 1. Altered level of consciousness Score 1 point per 2. Inattention domain present 3. Disorientation 4. Hallucination, delusion, or psychosis Delirium if > 4. 5. Psychomotor agitation or retardation 6. Inappropriate speech or mood Pooled Test Characteristics: 7. Sleep/wake cycle disturbances Sensitivity 74%. Specificity 82%. 8. Symptom fluctuation > Figure: Gusmao-Flores D. Crit Care. 2012;16:R115-R125. Screening: Implementation Strategies 1. Case-based scenarios Before-and-after case studies Strategy increased usage of the ICDSC by 70% and accuracy of assessment by 54%. 2,3. Spot-checking Systematic comparison of users with expert raters Identifies areas for fine tuning education Get it into the water Incorporate delirium into hospital nursing orientation 1.
8 Devlin JW Crit Care. 2008;12(1):R19. 2. Pun BT Crit Care Med. 2005;33(6):1199-1205. 3. Soja SL Intensive Care Med. 2008;34(7):1263-1268. Rounding Presentations: Emphasizing Mind and Body Pain Pain controlled or uncontrolled on (current analgesics). Most recent pain score, source of pain (when known). Agitation and Delirium Target RASS/SAS for the day Current RASS/SAS. Delirium status Current psychoactive medications Physical Activity Prior level of activity PT/OT consulted Target activity level for the day UCSF. RN rounding script Anticipating Delirium: Risk Factors Baseline Vulnerability Precipitants Underlying brain disease Medications (dementia, stroke, Parkinson) Infection Increased age Dehydration Institutionalization Immobility/restraints Chronic disease Malnutrition (HIV, HTN, ETOH dependency, Tubes/catheters diabetes, etc.)
9 Electrolyte imbalance Visual/hearing deficits Sleep deprivation Limits of Evidence: Delirium Prevention Perform early mobilization of adult ICU patients whenever feasible to reduce the incidence and duration of delirium (+1B). No recommendation for Using pharmacologic delirium prevention protocol Using combined nonpharmacologic and pharmacologic delirium prevention protocol as no compelling data demonstrate that these reduce the incidence or duration of delirium (0,C). We do not suggest that either haloperidol or atypical antipsychotics be administered to prevent delirium in adult ICU. patients (-2C). We provide no recommendation for the use of dexmedetomidine to prevent delirium in adult ICU patients, as there is no compelling evidence regarding its effectiveness in these patients (O,C).
10 Barr J Crit Care Med. 2013;41:263 306. Interventions for Delirium Early mobility and rehabilitation Sleep enhancement (via nonpharm and hygiene). Reducing unnecessary and deliriogenic medications Structured reorientation Adequate oxygenation American Geriatric Society 2014 Guidelines. J Am Geriat Soc. 2016;63(1):142-150. Inouye SK N Engl J Med. 1999;340(9):669-676. McNamara L. Am J Crit Care. 2008;17:576. Pain management Constipation relief Nutrition and fluid repletion Sensory assistive devices (vision and hearing). Cognitive stimulation/rehabilitation American Geriatric Society 2014 Guidelines. J Am Geriat Soc. 2016;63(1):142-150. Inouye SK N Engl J Med. 1999;340(9):669-676. McNamara L. Am J Crit Care. 2008;17:576. Wake Up, Breathe, and Exercise Dual center, RCT of 104 sedated, MV patients Both (B) SATs + SBTs for ALL patients Intervention patients If unresponsive, passive range of motion If following commands, PT/OT coordinated with DIS.